A View from Riggs: Treatment Resistance and Patient Authority—Introduction to Paper IX: Integrative Psychodynamic Treatment of Psychotic Disorders

In this ninth article in the Riggs series Jane Tillman addresses the treatment of psychotic spectrum disorders like schizophrenia. These are devastating disorders often thought of principally in terms of their acute phase presentations with delusions, hallucinations, pnoid beliefs, and unusual behavioral and mood manifestations. Yet, as we know, these disorders go much beyond the acute phase. Their diagnosis requires the presence of substantial and enduring prodromal or residual phase problems. As Tillman points out, these disorders are customarily treated with biological (i.e., pharmaceutical) treatments that, though effective in relieving many acute phase symptoms, leave affected individuals struggling with the problem of how to adapt and move on in their lives.

Although many of the patients with psychotic spectrum disorders whom we see at Riggs have had substantial prior treatment courses, it is remarkable how often they have not had much exposure to individual psychodynamic therapy. These treatment resistant individuals live in an era in which biology reigns supreme. Treaters rarely think of the value of a psychodynamic approach, and even more rarely have any substantial training or experience with it. Such psychosocial treatment as is available often is provided from a stance that views patients struggling with the residual phase of a psychotic disorder as less than fully competent individuals. They are often approached as individuals whose authority and voice are silenced in favor of a focus on the importance of “compliance” with treatment. Patients with psychotic spectrum disorders are at risk to be treated as if a psychotic diagnosis were interchangeable with a finding that they are legally incompetent and not able to think and act on their own behalf.

Our field has genuine blind spots and biases around the utility of psychodynamic treatment for psychotic spectrum disorders. Tillman